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Mosconi C, Calandri M, Mirarchi M, Vara G, Breatta AD, Cappelli A, Brandi N, Paccapelo A, De Benedittis C, Ricci C, Sassone M, Ravaioli M, Fronda M, Cucchetti A, Petrella E, Casadei R, Cescon M, Romagnoli R, Ercolani G, Giampalma E, Righi D, Fonio P, Golfieri R. Percutaneous management of postoperative Bile leak after hepato-pancreato-biliary surgery: a multi-center experience. HPB (Oxford) 2021; 23:1518-1524. [PMID: 33832832 DOI: 10.1016/j.hpb.2021.02.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 02/22/2021] [Accepted: 02/25/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Bile leak (BL) after hepato-pancreato-biliary (HPB) surgery is associated with significant morbidity and mortality. Aim of this study was to evaluate effectiveness and safety of percutaneous transhepatic approach (PTA) to drainage BL after HPB surgery. METHODS Between 2006 and 2018, consecutive patients who were referred to interventional radiology units of three tertiary referral hospitals were retrospectively identified. Technical success and clinical success were analyzed and evaluated according to surgery type, BL-site and grade, catheter size and biochemical variables. Complications of PTA were reported. RESULTS One-hundred-eighty-five patients underwent PTA for BL. Technical success was 100%. Clinical success was 78% with a median (range) resolution time of 21 (5-221) days. Increased clinical success was associated with patients who underwent hepaticresection (86%,p = 0,168) or cholecystectomy (86%,p = 0,112) while low success rate was associated to liver-transplantation (56%,p < 0,001). BL-site,grade, catheter size and AST/ALT levels were not associated with clinical success. ALT/AST high levels were correlated to short time resolution (17 vs 25 days, p = 0,037 and 16 vs 25 day, p = 0,011, respectively) Complications of PTA were documented in 21 (11%) patients. CONCLUSION This study based on a large cohort of patients demonstrated that PTA is a valid and safe approach in BL treatment after HPB surgery.
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Affiliation(s)
- Cristina Mosconi
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, 40138, Bologna, Italy
| | - Marco Calandri
- Radiology Unit, A.O.U. San Luigi Gonzaga di Orbassano, Regione Gonzole 10, 10043, Orbassano, Torino, Italy; Department of Oncology, University of Torino, Via Verdi 8, 10124, Torino, Italy
| | - Mariateresa Mirarchi
- General and Oncology Surgery, Morgagni-Pierantoni Hospital, Via Carlo Forlanini, 34, 47121, Forlì, Italy.
| | - Giulio Vara
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, 40138, Bologna, Italy
| | - Andrea D Breatta
- Radiology Unit, A.O.U. Città Della Salute e Della Scienza, Corso Bramante, 88, 10126, Torino, Italy
| | - Alberta Cappelli
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, 40138, Bologna, Italy
| | - Nicolò Brandi
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, 40138, Bologna, Italy
| | - Alexandro Paccapelo
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, 40138, Bologna, Italy
| | - Caterina De Benedittis
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, 40138, Bologna, Italy
| | - Claudio Ricci
- General Surgery and Transplantation Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Mirian Sassone
- Radiology Unit, A.O.U. Città Della Salute e Della Scienza, Corso Bramante, 88, 10126, Torino, Italy
| | - Matteo Ravaioli
- General Surgery and Transplantation Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Marco Fronda
- Radiology Unit, A.O.U. Città Della Salute e Della Scienza, Corso Bramante, 88, 10126, Torino, Italy
| | - Alessandro Cucchetti
- General and Oncology Surgery, Morgagni-Pierantoni Hospital, Via Carlo Forlanini, 34, 47121, Forlì, Italy
| | - Enrico Petrella
- Radiology Unit, Bufalini Hospital, Viale Giovanni Ghirotti, 286, 47521, Cesena, Italy
| | - Riccardo Casadei
- General Surgery and Transplantation Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Matteo Cescon
- General Surgery and Transplantation Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Renato Romagnoli
- Liver Transplant Unit "E.Curtoni", A.O.U. Città Della Salute e Della Scienza, Corso Bramante, 88, 10126, Torino, Italy; Department of Surgical Sciences, University of Torino, Via Verdi 8, 10124, Torino, Italy
| | - Giorgio Ercolani
- General and Oncology Surgery, Morgagni-Pierantoni Hospital, Via Carlo Forlanini, 34, 47121, Forlì, Italy
| | - Emanuela Giampalma
- Radiology Unit, Bufalini Hospital, Viale Giovanni Ghirotti, 286, 47521, Cesena, Italy
| | - Dorico Righi
- Radiology Unit, A.O.U. Città Della Salute e Della Scienza, Corso Bramante, 88, 10126, Torino, Italy
| | - Paolo Fonio
- Radiology Unit, A.O.U. Città Della Salute e Della Scienza, Corso Bramante, 88, 10126, Torino, Italy; Department of Surgical Sciences, University of Torino, Via Verdi 8, 10124, Torino, Italy
| | - Rita Golfieri
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, 40138, Bologna, Italy
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Citterio D, Vaiani M, Sposito C, Rossi RE, Flores M, Battiston C, Mazzaferro V. Improved management of grade B biliary leaks after complex liver resections using gadoxetic acid disodium-enhanced magnetic resonance cholangiography. Surgery 2021; 170:499-506. [PMID: 33745732 DOI: 10.1016/j.surg.2021.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 02/04/2021] [Accepted: 02/06/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Bile leaks occurring after complex liver resection and lasting >1 week (grade B) usually are managed by means of invasive cholangiography either endoscopic or percutaneous, with a substantial risk of procedure-related complications. The aim of this study was to investigate the ability of gadoxetic acid disodium-enhanced magnetic resonance cholangiography to detect postoperative biliary leaks and avoid invasive cholangiography in case of peripheral location of the fistula. METHODS Patients with grade B biliary leak after complex liver resection from January 2018 to March 2020 underwent magnetic resonance cholangiography to guide the management of the leak (study group). The primary endpoint was the ability of magnetic resonance cholangiography to reduce the need for invasive cholangiography with respect to similar posthepatectomy leaks collected in the previous 2 years and approached with upfront invasive cholangiography (controls). A series of in-hospital outcomes also were compared. RESULTS Out of 533 liver resections, 11 study patients versus 11 control patients with grade B leaks were compared. Magnetic resonance cholangiography achieved 100% accuracy in detection and location of the leak. Five out of 6 peripheral leaks healed without invasive cholangiography. Overall, 50% reduction in the use of invasive cholangiography was observed in the study versus control patients. Median healing time and hospital stay were 38 and 40 days in patients undergoing invasive cholangiography versus 10 and 11 days in patients treated conservatively (P = .007 and 0.012, respectively). Infection rate and other complications rate were 82% vs 20% (P = .01) and 35% vs 40% (P = .5), respectively. CONCLUSION Magnetic resonance cholangiography is a safe, precise, noninvasive tool to detect posthepatectomy bile leaks that can help clinicians in decision-making on conservative versus invasive treatment of fistulas.
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Affiliation(s)
- Davide Citterio
- HPB Surgery, Hepatology and Liver Transplantation, Fondazione IRCCS Istituto Nazionale Tumori di Milano, Milan, Italy
| | - Marta Vaiani
- Department of Radiology, Fondazione IRCCS Istituto Nazionale Tumori di Milano, Milan, Italy
| | - Carlo Sposito
- HPB Surgery, Hepatology and Liver Transplantation, Fondazione IRCCS Istituto Nazionale Tumori di Milano, Milan, Italy; Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Roberta Elisa Rossi
- HPB Surgery, Hepatology and Liver Transplantation, Fondazione IRCCS Istituto Nazionale Tumori di Milano, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Maria Flores
- HPB Surgery, Hepatology and Liver Transplantation, Fondazione IRCCS Istituto Nazionale Tumori di Milano, Milan, Italy
| | - Carlo Battiston
- HPB Surgery, Hepatology and Liver Transplantation, Fondazione IRCCS Istituto Nazionale Tumori di Milano, Milan, Italy
| | - Vincenzo Mazzaferro
- HPB Surgery, Hepatology and Liver Transplantation, Fondazione IRCCS Istituto Nazionale Tumori di Milano, Milan, Italy; Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy.
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Mutignani M, Dioscoridi L, Pugliese F, Cintolo M, Massad M, Forti E. Primary endotherapy for Strasberg type C bile leaks. Surgery 2019; 166:286-289. [PMID: 31109658 DOI: 10.1016/j.surg.2019.03.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 03/03/2019] [Accepted: 03/12/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Endotherapy is considered by some as the treatment of choice for most external biliary fistulas after laparoscopic cholecystectomy except for those originating from isolated/disconnected ducts, as in Strasberg type C lesions. Endoscopic intervention is not generally considered among treatment options because the isolated duct cannot be opacified during cholangiography and is inaccessible with the usual endoscopic methods. METHODS Our interventional endotherapy for this type of complication consists of cannulating the isolated duct by passing a guidewire out of the cystic duct or the disruption of the common bile duct into the pathway of the biliary fistula. The key element of this endoscopic treatment is to restore the continuity of the biliary tree. Our case series (from March 2012 to September 2017) consists of 19 patients (9 males, 10 females) with Strasberg type C bile leaks. The access to the transected biliary duct was obtained by purposeful puncture of the cystic duct stump into the peritoneal cavity and then intubation of the biliary duct by a 0.035 hydrophilic guidewire. In 17 cases, we performed direct cannulation of the isolated transected duct. In 2 cases, we performed an endoscopic "step-up approach" (a 2-session variant of the technique). RESULTS Technical and clinical success rates were both 100%. Drainage form the abdominal drain stopped in a mean of 1.2 days. There was 1 recurrence after 4 weeks (attributable to displacement of the metal stent), but we were able to retreat the patient endoscopically. Our technique is minimally invasive but very effective in healing the fistulas. Operative repair, in contrast, is a major operation with increased morbidity, prolonged hospital stay, and is more costly. Moreover, on the basis of the available literature, endotherapy passing through the abdominal cavity became safe in expert centers. CONCLUSION The described endoscopic treatment is innovative, safe, and effective and is applicable in tertiary-level centers but requires considerable interventional endoscopic expertise. This minimally invasive procedure can increase the rate of fistula healing and decreases the need for more aggressive and risky operative procedures.
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Affiliation(s)
| | - Lorenzo Dioscoridi
- Digestive and Operative Endoscopy Unit, Niguarda-Ca' Granda Hospital, Milan, Italy
| | - Francesco Pugliese
- Digestive and Operative Endoscopy Unit, Niguarda-Ca' Granda Hospital, Milan, Italy
| | - Marcello Cintolo
- Digestive and Operative Endoscopy Unit, Niguarda-Ca' Granda Hospital, Milan, Italy
| | - Mutaz Massad
- Digestive and Operative Endoscopy Unit, Niguarda-Ca' Granda Hospital, Milan, Italy
| | - Edoardo Forti
- Digestive and Operative Endoscopy Unit, Niguarda-Ca' Granda Hospital, Milan, Italy
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